Forms and Instructions for Weight Loss Surgery in Jacksonville

Our forms section provides you with several forms that you will wish to download and complete before visiting our office. Completing these forms before your visit will save you time and ensure that you have all of the necessary documents available for our medical team to review.

1. Financial Policy
   Financial Policy
2. HIPAA Notice
   Our privacy and HIPAA compliance policy
3. Medical Release Form
   Authorization for release of medical records to other agencies
4. Insurance Verification
   Notice of insurance verification for LAP-BAND surgery
5. Patient Responsibility Form
   Jacksonville Surgical Associates Patient Responsibility Agreement
6. Media Release Form
   Consent for taking and publishing photographs
7. Program Fee Form
   Program fee refund policy
8. Weight Loss Program Tax Deductions
   Internal Revenue Service policy (IRS Ruling 202-19)on deducting the cost of a weight-loss programs as a medical expense.

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